Tennis Elbow – Why Do Studies Show Acupuncture Has Only Short Term Benefits?
Patients frequently present to acupuncture clinics for treatment of ‘tennis elbow’ (TE). Often this condition has become chronic due to delayed presentation for treatment, or unsuccessful intervention with other modalities. According to the scientific literature acupuncture only gives temporary relief of the pain and dysfunction associated with TE. However many clinicians report successful treatment of this painful and debilitating condition. This paper examines the available evidence regarding acupuncture treatment of TE. The limitations of the studies are discussed with reference to Traditional Chinese Medicine (TCM) theory, as well as neuroanatomical considerations. The need to look beyond local structures and to identify other contributing factors that may prevent long-term resolution of TE, is also discussed.
In order to establish the availability of evidence supporting acupuncture treatment of TE, the following research question was developed: What evidence exists to suggest acupuncture treatment of tennis elbow will eliminate pain and inflammation, and improve function of the elbow joint?
Search terms were identified using the PICO format:
Population: people with tennis elbow
Outcomes: 1) elimination of pain and inflammation 2) improved elbow joint function
Keywords and their synonyms were identified and combined using the BOOLEAN operators AND and OR. Wildcards, truncation symbols and MeSH terms were utilised when available to ensure adequate coverage of the literature. The main search strategies were as follows:
#1) Tennis elbow
#2) Lateral epicondylitis
#3) Lateral epicondylalgia
#4) Lateral epicondyle pain
#5) Lateral elbow pain
#6) #1 OR #2 OR #3 OR #4 OR #5
#8) #6 AND #7
Databases searched include PubMed, DARE, Cochrane DSR, ACP Journal Club, CCTR , Journals@Ovid Full Text, YourJournals@Ovid, CINAHL, EMBASE, and AMED. Systematic reviews and randomised controlled trials were selected for analysis due to their high level of evidence rating (NHMRC 2005). The search results were then analysed for evidence relevant to the outcomes of interest.
Evaluating and defining TE
TE diagnosis usually involves evaluation of common symptoms and signs, accompanied by simple physical tests. This condition is a pain syndrome affecting the wrist extensors directly on, or in the proximity of, their origin at the lateral epicondyle (Trudel et al. 2004). A widely accepted definition of TE in a medical setting describes it as “epicondylar pain and epicondylar tenderness and pain on resisted extension of the wrist” (Alvarez-Nemegyei & Canosa 2004). Painful hand grip is a predominant symptom (Mellor 2003). As is tenderness of the proximal extensor muscle mass (Trudel et al. 2004). A common test for TE is to stabilise the patient’s forearm, ask the patient to extend their wrist, then actively resist flexion of the wrist by the practitioner. A positive test will elicit pain at the lateral epicondyle (Hoppenfeld 1976).
However debate continues regarding aetiology and the structures involved with TE. The extensor carpi radialis is believed to be consistently involved with TE. However the extensor digitorum is also implicated with some patients (Trudel et al. 2004). In addition, some MRI and histological studies suggest injury initially occurs in the proximal flexor carpi radialis brevis, before extending to the common extensor tendon (Alvarez-Nemegyei & Canosa 2004). These variable findings suggest the structures involved with TE have yet to be clearly defined. Furthermore histology reports find an absence of inflammatory markers associated with TE (Alvarez-Nemegyei & Canosa 2004). This contradicts the common medical diagnosis for TE of lateral epicondylitis, with the suffix itis suggesting an inflammatory process. Alvarez-Nemegyei & Canosa (2004), call for a re-categorisation of TE to an overuse tendinosis. By definition the term tendinosis refers to a chronic degenerative process(Marcus 2004). Indeed studies show cellular and vascular degeneration are key features of TE (Trudel et al. 2004). Consequently this paper will continue to refer to the term ‘tennis elbow’ due to the current lack of consensus of medical nomenclature for this condition.
Approximately 1 in 7000 patient visits to a general practitioner will be for TE (Bisset, Paungmali, Vicenzino, Beller & Herbert, 2005). Most cases will resolve within a year (Mellor 2003). However manual work and high levels of pain before intervention are linked to poorer prognosis (Haahr & Andersen 2003). Seventy five to 80% of elbow problems experienced by tennis players are thought to be due to TE.Up to 14% of the workforce engaged in highly repetitive or strenuous wrist and elbow movement also develop this condition (Alvarez-Nemegyei & Canosa 2004). Furthermore TE is thought to account for an average work absenteeism of around 12 weeks in approximately 30% of sufferers (Bisset, Paungmali, Vicenzino, Beller & Herbet, 2005). Consequently TE has a significant social and economic cost.
Treatment goals and study outcome measures
Pain relief, minimising aggravating movements, and muscle conditioning are considered primary rehabilitative goals for TE (Trudel at al, 2004). Study outcome measures utilised to evaluate progress towards these goals include: pain rating using a verbal rating scale or visual analogue scale (VAS); grip strength; and pain free grip strength. Adverse effects and patient satisfaction with treatment were also evaluated. Grip strength is measured using a vigorimeter or dynanometer (Davidson, Vandervoort, Lessard & Miller, 2001; Tsui P, 2002). These devices measure the amount of grip strength that can be applied without inducing pain and are considered to have a high degree of reliability as long as the elbow position is consistent in each test (Ng & Fan 2001). A pain VAS can be used to record pain-rating with grip strength. In this case the VAS could show a range from ‘no pain’ at one end, to ‘worst pain imaginable’ at the other end:
no pain worst possible pain
Lack of consensus regarding treatment
Despite numerous studies, and the prevalence of TE, there is little consensus regarding its treatment (Bisset, Paungmali, Vicenzino, Beller & Herbert 2005; Green et al 2006). In general, this is due to a paucity of unequivocal evidence either supporting or refuting current treatment (Trudel et al, 2004). Part of the problem appears to be the great variations in study designs and sizes, making it difficult for reviewers to draw clear conclusions.
Systematic reviews to determine the effectiveness of physiotherapy treatments for TE are inconclusive. Physiotherapy interventions reviewed include extracorporeal shock wave therapy, acupuncture, orthotics, mobilisations with movement, non-steroidal anti-inflammatory drugs, transverse friction massage, taping, laser, ultrasound, electro-magnetic field and ionisation therapy (Mellor 2003; Smidt et al, 2003). However no conclusions were drawn regarding the effectiveness of any of the treatments. Similarly there is a lack of evidence supporting or refuting surgical intervention and cortisone injection (Trinh, Phillips, Ho & Damsma, 2004). Cortisone injection appears to only give short term relief and there may be risk of further injury during this time due to pain masking (Boisaubert, Brousse, Zaoui, Montigny, 2004; Mellor 2003). On the other hand, a systematic review by Bisset et al (2005) suggests stretches and exercises may help reduce pain. They also suggest elbow manipulation may help in the early stages of treatment. Interestingly, despite evidence suggesting a lack of inflammatory markers, oral or topical non-steroidal anti-inflammatory drugs in conjunction with avoidance of aggravating activities, may be helpful in early stage TE (Alvarez-Nemegyei & Canosa, 2004; Mellor 2003).
Various hypotheses have been proposed to explain the biomedical actions associated with acupuncture treatment of TE (Zijlstra, van den Berg-de Lange, Huygen, Klein, 2003). Neurotransmitters such as serotonin, E-endorphin, methionine enkephalin and dynorphins are believed to be involved with acupuncture’s analgesic effect (Tsui 2002). However the effect of acupuncture on the associated underlying pathologies is not yet understood and large randomised trials are required to confirm various hypotheses (Zijlstra, van den Berg-de Lange, Huygen, Klein, 2003).
Regardless of the mechanisms involved, systematic reviews suggest acupuncture treatment of TE has a short term benefit of 2-8 weeks (Bisset, Paungmali, Vicenzino, Beller & Herbert, 2005; Green et al 2006; Trinh, Phillips, Ho & Damsma, 2004). However the review authors also discuss the difficulties of evaluating the evidence due to great clinical heterogeneity and inconsistent descriptions of TE between studies. Treatment number and frequency, point selection, outcome measures and control group intervention/sham varied greatly between studies. A German single blind randomised control trial, demonstrated the immediate analgesic effect on TE, of manually stimulating Yanglingquan (GB 34) (Molsberger, 1994). This point was needled until de qi sensation was obtained. Patients were asked to move the elbow during needling and needles were retained for 5 minutes. The placebo group had the skin of Feishu (UB 13) stimulated with a probe. Pain with movement, loading and pressure was evaluated using a 0 – 10 scale with 0 meaning no pain and 10 meaning worst pain imaginable. Acupuncture was judged to have had a beneficial effect if pain was reduced by 50%. The treatment group had a pain reduction of 79.2% and the placebo group 25%. A p-value of 0.01% was calculated and consequently the trial results were considered to be statistically significant.
Another trial comparing needling of a prescribed set of acupuncture points to non-specific needling, consisted of treatments twice weekly for a total of 10 treatments (Fink, Wolkenstein, Karst & Gehrke, 2002). The acupuncture points chosen were Shousanli (LI 10), Quchi (LI 11), Ligou (LIV 5), one ashi, Hegu (LI 4) and Waiguan (SJ 5). De qi was obtained at the muscle level and needles were retained for 25 minutes. The control group was needled in areas not corresponding to regular acupuncture points, meridians, ashi or trigger points. Follow up was over a period of 2 months post treatment. At 2 weeks the acupuncture group showed greater improvement in pain intensity, arm function and maximal strength. At two months only arm function was better than in the control group. However the lack of a non-intervention control group means we are unable to compare these results to the natural course of disease.
Similar acupuncture points were needled in another trial comparing acupuncture to ultrasound (Davidson, Vandervoort, Lessard & Miller, 2001). Needles were stimulated to obtain de qi sensation every 5 minutes, and were retained for 20 minutes in total. Treatment was given 2-3 times per week for 8 treatments in each group. This study showed no overall difference in outcomes between the two groups. However once again, no comparison was made to a non-intervention group.
Another study demonstrated that needling similar points to the standard needle depth and obtaining de qi sensation every 5 minutes, was more effective than superficially needling the same points without obtaining de qi sensation (Haker, 1990). This study suggests de qi sensation affects the pain relieving properties of acupuncture. However the effect over time was not evaluated.
Brattberg (1983), compared needling local acupuncture points on patients unsuccessfully treated with steroid injection, to steroid injection treatment alone. A questionnaire evaluated the degree of pain after treatment. Follow up was over a period of 12 months. The acupuncture group was treated 1-2 times per week, with an average of 6 treatments completed over a period of 4 weeks. This study showed similar improvements in both groups, suggesting acupuncture may be a viable alternative to steroid injection.
Twenty participants were evaluated to compare manual acupuncture (MA) with electro-acupuncture (EA) treatment of TE (Tsui 2002). Both these interventions were compared to a non-intervention control group. The points Tiaokou (ST 38) and Yangliangquan (GB 34) were stimulated and the needles retained for 20 minutes. Treatment was given three times weekly for 2 weeks. Both intervention groups were instructed to flex and extend the affected joint 50 times over 5 minutes during needling. The EA group received electro-stimulation for the full needle retention time. MA showed a 32% improvement in pain, while EA showed 50%. The untreated group had a 5% improvement. Pain free hand grip for both EA and MA showed high statistical significance with p-values of 0.000 and 0.003 respectively, when compared to the untreated group.
Summarising these studies demonstrates the variety of methods used to evaluate acupuncture treatment of TE. Moreover none of the studies show acupuncture had a long-term advantage over other treatments or non-treatment. Of significance to TCM acupuncturists is that all the studies prescribed a generic set of points, with no consideration of the individual pattern of disharmony or presentation associated with each patient. The problem of inadequate treatment administration in acupuncture trials is discussed by Birch (2004). Standardisation of acupuncture intervention to satisfy the scientific community restricts the true application of TCM acupuncture, and is highly likely to minimise the long-term benefits of treatment. I also propose that musculoskeletal structures other than the wrist extensors can contribute to chronic tennis elbow and inhibit satisfactory treatment outcomes, if not accounted for in patient evaluation.
Clinical evaluation of TE from a TCM perspective
TCM uses the term ‘Sinews’ to encompass a number of types of soft tissues, including tendons (Marcus, 2004). According to TCM, tendons are controlled by the Liver. In particular they are nourished by the Liver Blood, which allows flexibility and smooth joint movement (Maciocia, 1989).
Overuse of the involved tendons appears to be a trigger for many cases of TE. TCM recognises that overuse of a body part may stagnate the flow of Qi in that area, injuring Sinews and causing subsequent pain and inflammation (Maciocia, 1989). This is commonly diagnosed as a Painful Obstruction syndrome (Marcus, 2004). Painful Obstruction Syndrome occurs when Qi and Blood, or Qi, Blood and Phlegm stagnation occurs in the Muscle Sinew channels (Marcus, 2004; O'Connor & Bensky, 1981). This stagnation may further compromise the affected area by inhibiting the local supply of Qi and Blood required for healing (Maciocia, 1989).
Furthermore, weakening of musculoskeletal structures may allow external pathogens such as Wind, Heat, Cold or Damp to invade them (Maciocia, 1994). Wind and Cold are particularly indicated in TE (Flaws & Sionneau, 2001). Pathogenic invasion can complicate or reduce the effectiveness of many treatments. Differentiation of pain quality and character is an important part of diagnosing which pathogens are involved (see Table 1):
Generalised/distending/pulsing; often affected by emotions/stress; better with pressure e.g massage
Sharp/fixed/local: often worse at night; worse with pressure
Moving/changeable; often sudden onset
Contracting/spastic/constant/severe; worse with cold; relieved by warmth
Hot/swollen; aggravated by heat; relieved with cold
Swelling/numbness/heaviness; affected by weather changes
Table 1. TCM pain/pathogen differentiation (Legge, 1990; Marcus, 2004; Vangermeersch & Sun, 1994).
On the other hand generalised deficiency of Qi, Blood and Body Fluids (Jin Ye) can prevent adequate tendon nourishment, and subsequently predispose them to injury (Maciocia, 1989). Blood production requires good nutrition and hydration as well as strong Spleen and Stomach Qi. Weak Spleen or Stomach Qi impairs their ability to extract Gu Qi from food. Blood production requires Gu Qi to be sent up to the Lungs, and then to the Heart where it is transformed into Blood (Maciocia, 1989). This transformation is assisted by the Original Qi and Kidney Essence stored in the bone marrow. Consequently poor Lung and Heart function, or Kidney deficiency can also contribute to Blood deficiency, and subsequently to tendon pathologies. Alternatively Blood deficiency can occur as a result of chronic disease or excessive bleeding, such as haemorrhaging or menorrhagia (McDonald & Penner, 1994).
Jin Ye refers to the fluids of the body. Jin fluids are those that warm and moisten muscles and skin (Cheng, 1987). Ye fluids are thicker and are involved with moistening, lubricating and nourishing joints (Clavey, 2003). Consequently Ye fluids correlate with the western biomedical concept of synovial fluid (Marcus, 2004). Ye fluids are particularly related to the Spleen, Stomach and Kidneys. The Kidneys control Jin Ye and are considered to be the “root” of Fluids (Ni, 1995). The Spleen and Stomach are involved with absorption and transformation of food and water into Fluids, and their transportation throughout the body (Clavey, 2003; Marcus, 2004). Consequently poor Spleen/Stomach or Kidney function can lead to insufficient Jin Ye production. Jin Ye can also be exhausted if the body becomes severely dehydrated, such as in extreme heat or with excessive sweating (Clavey, 2003).
As discussed, TCM considers a number of contributing underlying pathologies when evaluating TE. Treatment of these imbalances may be significant for preventing reoccurrence of symptoms. Consequently treatment should vary according to diagnosis and presentation.
Evaluation of a patient presenting with TE should include a thorough assessment of the structures involved. Performance tests for TE should be utilised as part of the initial investigation, and the results documented (Beattie, 2001). In addition the entire arm, shoulder, neck and upper back should be palpated, range of motion evaluated and any associated signs and symptoms noted. An evaluation of the patients normal posture, and posture associated with activities that trigger TE symptoms, may also be necessary.
Details regarding associated pain and dysfunction should also be recorded. This information is important for monitoring treatment progression and evaluating treatment outcome at follow up. A pain VAS can be used to monitor particular areas of difficulty associated with activities of daily living (ADL). A simple format for recording this information could be:
no pain worst possible pain
A VAS scale can also be used to rate function. This scale quantifies a patient’s ability to perform an activity in comparison to their ability prior to onset of TE symptoms. A functional VAS scale could look like this:
unable to perform able to perform to same level as prior to TE
Neuroanatomical considerations for acupuncture
Tendons can be considered as thickened areas of fascia (Schleip, Klingler & Lehmann-Horn, 2005). Recent studies suggests fascia has a contractile response that may assist in strengthening structures undergoing high biomechanical or stress loading (Schleip, Klingler & Lehmann-Horn, 2005). Furthermore intermuscular and intramuscular connective tissue is connected (Huijing & Baan, 2001). This is of significance to acupuncture due to the dominant location of acupuncture points along connective tissue planes (Langevin & Yandow, 2002). Acupuncture may consequently release contracted fascia contributing to TE symptoms.
Trigger points (TP) may also be significant in the development and treatment of TE. TP are located in the myofascia and when activated produce a characteristic pain referral pattern (AHFMR, 2002; Travell & Simons, 1999). Myofascial pain has been linked to muscles, their surrounding fascia and associated attachments (Bradley, 1988). Biomechanical force such as muscle overload and repetitive mechanical stresses may activate TP, causing pain (Travell & Simons, 1999). TP are often treated by direct needling, typically involving injection of a variety of substances. However studies suggest the needling effect is independent of the injected substance (Cummings & White, 2001). Furthermore the magnitude of the needling effect on a tissue plane varies, depending on needle material and diameter (Langevin & Yandow, 2002). Needle grasp is significantly diminished with needle diameters over 1mm (Langevin et al, 2002). Acupuncture needle manipulation has been found to directly affect fascia by winding the tissues around the needle, creating friction and propagating a mechanical signal along the tissue plane (Langevin et al, 2002). This ‘needle grasp’ interaction may have a long lasting effect on connective tissue.
Furthermore this effect is stronger at acupuncture points than non-points. Active TP correspond to ashi points. In TCM, trigger points may be used to treat Sinew channel pathologies (Marcus, 2004). However it is my own clinical observation that there does not appear to be one Sinew Channel involved with chronic TE. If anything, there may be a combination of Sinew channels involved.
There are particular TP that may be of significance in the treatment of TE. I have found the serratus posterior superior (SPS) muscle and its TP located close to Gaohuangshu (UB 43) to be particularly useful (Legge, 2005). The pain distribution from this TP radiates from the medial scapula, then anterior to the scapula, across the posterior shoulder and arm to the lateral epicondyle of the elbow, then down the forearm and hand along the Small Intestine channel (Legge, 2005). I frequently find that with palpation, many TE patients feel significant tenderness along this pain distribution, particularly around Gaohuangshu (UB 43), Naoshu (SI 10) and along the SI channel of the posterior brachium. According to Legge (2005), the SPS muscle can be overworked as a consequence of chronic coughing or laboured respiration. In addition, ribs can be depressed and the SPS muscle fibres stretched, as a result of a stooped/slumped posture involving elevation or anterior rolling of the shoulders. These conditions can all activate the associated TP (Legge, 2005). In particular, poor posture may significantly contribute to TE. Many of my TE patients have occupations that contribute to compromised upper back and shoulder posture e.g carpenters, dressmakers, massage therapists, and desk workers. Double needling the trigger point approximated to Gaohuangshu (UB 43), at a superficial-oblique angle in a lateral direction to a depth of 1-1.5 cun, accompanied by mild electro-stimulation through these two needles, appears to be particularly helpful in these cases.
Other TP not located in the immediate proximity, but which have a strong referral pattern to the lateral elbow, include the supraspinatus and the scaleni (Travell & Simons, 1999). These are areas that are also frequently painful with palpation in TE patients. Scaleni trigger points can also cause the development of secondary TP in the triceps brachii, extensor digitorum and brachioradialis. These can be identified by palpating the associated San Jiao and Large Intestine meridians. The supraspinatus is an important stabilising muscle for the gleno-humeral joint (Travell & Simons, 1999). Its trigger points can be activated by carrying heavy loads with the arm hanging down, pulling forces on the arm, or repetitive or loaded movements elevating the arms to or above the shoulder.
In addition, treating the cervical spine area may also be of benefit. In particular it is important to investigate possible cervical spine problems that may refer pain to the elbow (Hoppenfeld, 1976). However because the arm is innervated by the distribution from the brachial plexus, I also treat the Hwatojiaji points corresponding to the spinal innervation of the muscles with identified TP involvement. This was a technique I learned a number of years ago and which I have found to be extremely effective for most types of arm pain.
Acupuncture treatment of TE may need to be more comprehensive than indicated in the scientific literature. According to TCM theory, nourishment of tendons requires healthy function of the zang fu, as well as adequate production and circulation of Qi, Blood and Jing Ye. Consequently evaluating the presence of any associated underlying imbalances in the body should influence treatment planning. Furthermore the neuroanatomy associated with chronic TE may be more complex than suggested by the types of points chosen in the studies. My own experience suggests that in chronic stage TE, local treatment alone is insufficient for resolution of this condition. According to TCM theory, treatment should always be individualised for each patient, taking into account each unique presentation. Full resolution of TE may require addressing underlying zang fu and jing luo pathologies. Furthermore a more comprehensive and individualised analysis of the neuroanatomical associations with TE may need to be considered. Further studies are required to evaluate the long term effect of this more holistic approach to acupuncture treatment of TE.
Suzanne Tapper has been in private practice since 1993. Since 2000, Suzanne has been a lecturer and clinical supervisor at the New Zealand College of Chinese Medicine. In 2006 Suzanne completed a Masters Degree in Traditional Chinese Medicine with the University of Western Sydney.
First published in the NZRA Journal of TCM.
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